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General NPI Number Information
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NPI Number | 1760111082
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Entity Type | Individual
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Provider Name | DARA J. EZZELL-PEBWORTH LMSW
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Gender | Female
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Dates
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Enumeration Date | 06/10/2022
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Last Update Date | 05/14/2024
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Provider Practice Location Address
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Address Line | 28371 EL PASO RD BLDG A
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City | CALDWELL
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State | ID
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Zip | 83607-7521
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Country | US
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Telephone | 208-972-5514
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Fax |
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Provider Business Mailing Address
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Address Line | 1871 SPANISH FORK WAY APT N204
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City | MERIDIAN
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State | ID
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Zip | 83642-5650
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Country | US
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Telephone | 208-389-8338
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 42343
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License Number State | ID
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